31 Pa. Code § 154.12 - Direct enrollee access to obstetrical and gynecological services

(a) Managed care plans shall permit enrollees direct access to obstetrical and gynecological services for maternity and gynecological care, including medically necessary and appropriate follow-up care and referrals, for diagnostic testing related to maternity and gynecological care from participating health care providers without prior approval from a primary care provider. No time restrictions shall apply to the direct accessing of these services by enrollees.

(b) A managed care plan may require a provider of obstetrical or gynecological services to obtain prior authorization for selected services such as diagnostic testing or subspecialty care-for example, reproductive endocrinology, oncologic gynecology and maternal and fetal medicine.

(c) A directly accessed participating health care provider providing services to an enrollee who has direct access to the provider in accordance with section 2111(7) of the act (40 P. S. § 991.2111(7)) and this section, shall inform the enrollee's primary care provider, of all health care services provided to the enrollee. The health care provider shall communicate the information within 30 days of the services being provided under procedures established by the managed care plan. For routine obstetrical services, an initial notification and final notification, subsequent to the postpartum visit, shall meet the notification requirements.

(d) Managed care plans may not have different reimbursement levels for covered services because an enrollee obtains these services through direct access rather than with the prior approval of a primary care provider.

Notes

31 Pa. Code § 154.12